Healthcare Provider Details

I. General information

NPI: 1013735026
Provider Name (Legal Business Name): NICOLE ODURO OWUSU LCMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 QUINCE ORCHARD RD # 250
GAITHERSBURG MD
20878-1437
US

IV. Provider business mailing address

555 QUINCE ORCHARD RD
GAITHERSBURG MD
20878-1437
US

V. Phone/Fax

Practice location:
  • Phone: 301-276-7031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number203562
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLCM1094
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: